Oropharyngeal Cancer and HPV — MCQs
Which of the following is not directly implicated as a cause of squamous cell carcinoma of the head and neck?
Commonest site of carcinoma tongue -
In carcinoma of the base of tongue, pain is referred to the ear through
65 year old man with carcinoma of tongue of > 4 cm size and multiple lymph nodes of > 6 cm noted. What is the AJCC staging?
Not true about glottic carcinoma
Which HPV oncoprotein initiates cervical carcinogenesis primarily by inactivating the p53 tumor suppressor?
A 26-year-old male presents to the outpatient department with a discrete thyroid swelling. On neck ultrasound, an isolated cystic swelling of the gland is seen. What is the risk of malignancy associated with this finding?
Most common presentation in nasopharyngeal carcinoma is with:
A patient presents with a cheek cancer of 2.5 cm size, which is close to and involves the alveolus, and is associated with a single mobile cervical lymph node of 6 cm size. What is the TNM staging?
True about tongue cancer:
Oropharyngeal Cancer and HPV Indian Medical PG Practice Questions and MCQs
Question 1: Which of the following is not directly implicated as a cause of squamous cell carcinoma of the head and neck?
- A. EBV
- B. HPV
- C. Betel Nut
- D. Vitamin A deficiency (Correct Answer)
Explanation: ***Vitamin A*** - Vitamin A deficiency is associated with increased risk of squamous metaplasia but not a direct cause of squamous cell carcinoma in the head and neck. - Adequate levels of Vitamin A are actually protective against various epithelial cancers. *EBV* - Epstein-Barr Virus (EBV) is linked to certain types of cancers, including nasopharyngeal carcinoma, but is not a major causative factor for squamous cell carcinoma [1]. - It can contribute to **lymphoproliferative disorders** but not primarily to squamous cell carcinoma of the head and neck [1]. *HPV* - Human Papillomavirus (HPV), particularly types 16 and 18, are recognized as significant contributors to oropharyngeal squamous cell carcinoma [1]. - HPV infection can lead to **malignant transformation** of epithelial cells [1]. *Betel Nut* - Betel nut chewing is a well-established risk factor for oral squamous cell carcinoma, associated with its carcinogenic properties [2]. - It can cause **oral lesions** and dysplasia, contributing significantly to the etiology of head and neck cancers [2].
Question 2: Commonest site of carcinoma tongue -
- A. Apical
- B. Lateral borders (Correct Answer)
- C. Dorsum
- D. Posterior 1/3
Explanation: ***Lateral borders*** - The **lateral borders** of the tongue are the most common site for squamous cell carcinoma due to chronic irritation from teeth, dental appliances, and exposure to carcinogens. - This area is subjected to considerable mechanical stress and chemical exposure, making it more susceptible to malignant transformation. *Apical* - While the apex (tip) of the tongue can be affected, it is **less common** compared to the lateral borders. - Tumors in this location may present earlier due to their prominent position, but incidence rates are lower. *Dorsum* - The **dorsum** (top surface) of the tongue is covered by papillae which provide some protective barrier, making it a **less frequent site** for carcinoma. - Carcinomas on the dorsum are often associated with other risk factors like syphilis or immunosuppression. *Posterior 1/3* - Carcinomas of the **posterior one-third** (base of the tongue) are often associated with **Human Papillomavirus (HPV)** infection. - These are typically harder to detect early due to their location and may present with different symptoms such as dysphagia or referred otalgia, but they are not the most common overall site.
Question 3: In carcinoma of the base of tongue, pain is referred to the ear through
- A. Trochlear
- B. Abducent
- C. Glossopharyngeal (Correct Answer)
- D. Olfactory
Explanation: ***Glossopharyngeal*** - The **glossopharyngeal nerve (cranial nerve IX)** innervates the posterior one-third of the tongue and contributes to sensation in the pharynx. [1] - Due to shared neural pathways with the ear through the **otic ganglion** and **tympanic plexus**, pain from the base of the tongue can be referred to the ear. *Trochlear* - The **trochlear nerve (cranial nerve IV)** is a motor nerve that innervates the superior oblique muscle of the eye. - It is solely responsible for eye movement and has no sensory innervation of the tongue or ear. *Abducent* - The **abducent nerve (cranial nerve VI)** is a motor nerve that innervates the lateral rectus muscle of the eye. - Like the trochlear nerve, it is involved in eye movement and plays no role in tongue sensation or ear pain referral. *Olfactory* - The **olfactory nerve (cranial nerve I)** is a special sensory nerve responsible for the sense of smell. [1] - It has no connection to pain sensation from the tongue or referral of pain to the ear.
Question 4: 65 year old man with carcinoma of tongue of > 4 cm size and multiple lymph nodes of > 6 cm noted. What is the AJCC staging?
- A. T3 N3 M0 (Correct Answer)
- B. T2 N3 M0
- C. T3 N2 M0
- D. T2 N2 M0
Explanation: ***T3 N3 M0*** - The primary tumor (T) is classified as **T3** because its greatest dimension is greater than 4 cm (or any tumor with depth of invasion > 10 mm). - The nodal involvement (N) is classified as **N3** (specifically **N3a**) because any lymph node greater than 6 cm, regardless of number, qualifies as N3a per **AJCC 8th Edition** staging. - This is the correct staging based on the clinical findings provided. *T2 N3 M0* - This is incorrect because a tumor > 4 cm automatically classifies as **T3**, not T2. - **T2** is reserved for tumors > 2 cm but ≤ 4 cm with depth of invasion ≤ 10 mm, or tumors ≤ 2 cm with depth of invasion > 5 mm and ≤ 10 mm. - While the N3 classification is correct, the T staging is wrong. *T3 N2 M0* - This is incorrect because although **T3** is correct for a tumor > 4 cm, the nodal classification is wrong. - Any lymph node > 6 cm is classified as **N3a**, not N2. - **N2** classifications require all involved nodes to be ≤ 6 cm in size. *T2 N2 M0* - This is incorrect as both the T and N classifications are inaccurate. - A tumor > 4 cm is **T3**, not T2. - Lymph node(s) > 6 cm are **N3a**, not N2. - This represents understaging of both the primary tumor and nodal disease.
Question 5: Not true about glottic carcinoma
- A. Is most common site in carcinoma larynx
- B. Presents early
- C. Has worst prognosis (Correct Answer)
- D. Most common in males
Explanation: ***Has worst prognosis*** - Glottic carcinoma generally has a **good prognosis** due to its early presentation with hoarseness and relative lack of lymphatic dissemination. - The statement that it has the **worst prognosis** among laryngeal carcinomas is incorrect; supraglottic and subglottic carcinomas often have poorer prognoses. *Is most common site in carcinoma larynx* - The **glottis** (true vocal cords) is indeed the **most common site** for laryngeal squamous cell carcinoma, accounting for about 60-70% of cases. - This anatomical location is prone to neoplastic changes due to exposure to carcinogens. *Presents early* - Glottic carcinoma typically presents **early** with **hoarseness of voice** as the tumor interferes with vocal cord vibration. - This early symptom often leads to prompt medical attention, allowing for early diagnosis and treatment. *Most common in males* - Laryngeal carcinoma, including glottic carcinoma, is significantly **more common in males** than females, with a male-to-female ratio of about 4:1. - This gender disparity is primarily attributed to higher rates of smoking and alcohol consumption in men. *Has good prognosis due to least lymphatic supply.* - The **glottis** has a relatively **sparse lymphatic drainage** compared to the supraglottis and subglottis. - This limited lymphatic supply leads to a lower risk of **early nodal metastasis**, contributing to the overall good prognosis.
Question 6: Which HPV oncoprotein initiates cervical carcinogenesis primarily by inactivating the p53 tumor suppressor?
- A. E3
- B. E5
- C. E6 (Correct Answer)
- D. E7
Explanation: ***E6*** - **E6 oncoprotein is the HPV protein that specifically targets and degrades p53** through ubiquitin-mediated proteolysis [2]. - **p53 degradation** prevents apoptosis and allows cells with damaged DNA to survive and proliferate, a critical early step in malignant transformation [3]. - E6 works synergistically with E7 in cervical carcinogenesis, but **E6 is uniquely responsible for p53 inactivation** [1]. *E3* - HPV does not have a clinically significant E3 oncoprotein in the context of cervical cancer pathogenesis. - This is not a major viral oncoprotein involved in malignant transformation. *E5* - **E5 oncoprotein** plays a minor role in early infection by enhancing growth factor receptor signaling. - It does **not target p53** and is often lost during viral integration, making it less critical for malignant progression. *E7* - **E7 oncoprotein targets the retinoblastoma protein (Rb)**, not p53 [1]. - Rb inactivation releases E2F transcription factors, driving cell cycle progression [1]. - E7 and E6 work together, but **E7's specific target is Rb, not p53** [1]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Neoplasia, pp. 334-335. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Female Genital Tract, pp. 1006-1007. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Neoplasia, pp. 303-304.
Question 7: A 26-year-old male presents to the outpatient department with a discrete thyroid swelling. On neck ultrasound, an isolated cystic swelling of the gland is seen. What is the risk of malignancy associated with this finding?
- A. 48%
- B. 12%
- C. 24%
- D. 3% (Correct Answer)
Explanation: ***3%*** - **Purely cystic thyroid nodules** (as described in this case with "isolated cystic swelling") have a **very low risk of malignancy**, typically **2-3%** or less. - According to **ATA guidelines** and **TIRADS classification**, purely cystic nodules are considered **low suspicion** lesions. - The cystic nature suggests a **benign process** such as a degenerated adenoma, colloid cyst, or simple cyst. - **Fine needle aspiration (FNA)** may still be considered if the nodule is >2 cm or has any suspicious solid components, but is often not required for purely cystic lesions. *48%* - This percentage is **significantly higher** than the actual malignancy risk for a purely cystic thyroid swelling. - Such a **high risk** would typically be associated with **solid nodules** exhibiting highly suspicious ultrasound features such as: - Microcalcifications - Irregular or spiculated margins - Taller-than-wide shape - Marked hypoechogenicity - Extrathyroidal extension *24%* - This percentage represents a **moderate to high risk** of malignancy, which is **not characteristic** of an isolated purely cystic thyroid swelling. - A risk in this range might be seen with: - **Mixed solid-cystic nodules** with predominantly solid components - Solid nodules with **intermediate suspicious features** on ultrasound *12%* - While lower than 24% or 48%, 12% is still **considerably higher** than the generally accepted malignancy risk for purely cystic thyroid nodules. - This risk level could be plausible for: - **Predominantly cystic nodules** with some eccentric solid components - Solid nodules with **mildly suspicious** features on ultrasound
Question 8: Most common presentation in nasopharyngeal carcinoma is with:
- A. Cervical lymphadenopathy (Correct Answer)
- B. Epistaxis
- C. Hoarseness of voice
- D. Nasal stuffiness
Explanation: ***Cervical lymphadenopathy*** - **Cervical lymphadenopathy** is the most frequent initial symptom, with over 75% of patients presenting with a palpable neck mass, often a **painless, firm mass** in the upper deep cervical chain. - This is due to the rich lymphatic drainage of the nasopharynx to the cervical lymph nodes, leading to early metastasis. *Epistaxis* - While **epistaxis** (nosebleeds) can occur in nasopharyngeal carcinoma, it is generally not the most common presenting symptom. - It usually presents as recurrent, mild **epistaxis** or bloody discharge rather than severe bleeding. *Hoarseness of voice* - **Hoarseness of voice** is typically associated with laryngeal involvement or recurrent laryngeal nerve palsy, which is a less common and usually later manifestation of nasopharyngeal carcinoma. - Primary nasopharyngeal tumors do not directly cause hoarseness unless they extend significantly or metastasize to structures affecting vocal cord function. *Nasal stuffiness* - **Nasal stuffiness** or obstruction can be a symptom due to tumor growth within the nasopharynx. - However, it is a less specific symptom and often overshadowed by the more prominent presentation of cervical lymphadenopathy.
Question 9: A patient presents with a cheek cancer of 2.5 cm size, which is close to and involves the alveolus, and is associated with a single mobile cervical lymph node of 6 cm size. What is the TNM staging?
- A. T3 N2
- B. T4 N2 (Correct Answer)
- C. T3 N3
- D. T4 N3
Explanation: ***T4 N2*** - The primary tumor involving the **alveolus (cortical bone invasion)** is classified as **T4a** regardless of size according to AJCC TNM staging for oral cavity cancers. - A single mobile ipsilateral cervical lymph node of **6 cm** is classified as **N2a** (single ipsilateral node, 3-6 cm in greatest dimension). - Therefore, the correct staging is **T4 N2**. *T3 N2* - **T3 classification is incorrect** as alveolar involvement (cortical bone invasion) automatically upgrades the tumor to T4a. - While N2 is correct for a single 6 cm node, the T-stage is underestimated. *T4 N3* - While **T4 is correct** due to alveolar bone involvement, **N3 is incorrect**. - **N3a requires lymph nodes >6 cm** (greater than 6 cm), not equal to 6 cm. - A single 6 cm node falls within the N2a category (3-6 cm range). *T3 N3* - **Both T3 and N3 are incorrect** for this presentation. - Alveolar involvement mandates T4 staging, and a 6 cm node is N2a, not N3.
Question 10: True about tongue cancer:
- A. Slurring of speech is a common complaint
- B. MC site is on Lateral margin (Correct Answer)
- C. Cervical lymph node metastasis is universally present
- D. Most common type is adenocarcinoma
Explanation: ***MC site is on Lateral margin*** - The **lateral border** of the tongue is the most common site for squamous cell carcinoma (SCC) of the tongue due to chronic irritation and exposure to carcinogens. - This anatomical location makes it susceptible to tumor development due to constant friction and potential for trauma. *Slurring of speech is a common complaint* - While speech can be affected by advanced tongue cancer, **dysarthria** (slurring of speech) is not typically an early or primary complaint. - Early symptoms often include a **painless lesion**, ulcer, or lump on the tongue. *Cervical lymph node metastasis is universally present* - While **cervical lymph node metastasis** is common in tongue cancer, its presence is not universal at diagnosis. - The incidence of metastasis varies depending on tumor size, depth of invasion, and location, ranging from 30% to 50% in early stages. *Most common type is adenocarcinoma* - The vast majority of tongue cancers, over 90%, are **squamous cell carcinomas (SCCs)**, arising from the epithelial cells. - **Adenocarcinoma** is a rare type of tongue cancer, originating from glandular tissue, and is not the most common histological type.
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